HomeMy WebLinkAboutR2023-0248 - Permit ApplicationPrint Form City of Newport Beach RECEIVED BY
COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION MAR 2 9 2023
100 Civic Center Drive i P.O. Box 1768 i Newport Beach, CA92658-8915
023 - p Z-y C6 www.newportbeachca.gov 1 (949) 644-3200
CITY of
Application for Report of Residential Building Records NEWPORT BEACH
Application Fee: - $202.00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type or print and complete all information
#of Units: F— Address: SF�o�l ,Q/(/I 6- City: Newport Beach State: CA Zip: q�
Property Owner: &rr Ij�0 Ilaw (57Zz/C Zip Code: i1-31925-
Owner Address: 8f� /Vr, City: if 01e4l�o
State: CA Zip Code: g2[DZS Home Phone:
Owner's Authorized Agent: Q � �✓Work Phone: 7/7 32Z � 7d
Agent Address: &C-/ 1 a, City:.7�,4 j tq.. Div— N4,L, � 2! „�f5,..
State: F� Zip Code: ��S ('�yyly Agent Email Address: / / SC✓f ✓19Cy�7 I Y
Escrow Company: A/D, V1/%m / L I0NC SSUZalN Escrow #: �7 fO lPs- �J
Escrow Address: 9&71 1?6ge � &1/0 5-rC 1 V3 City: 1g7V i___- &W-H
State: I / I Zip Code: q' CLegC- Escrow Phone: 7/tYJ g622 Z _ L)��
EmailReportto: �er/y/2� %� Se�b(,,c�, yf/j
For Inspection call (Name):' I ��n/i/v Direct Phone: -71Y �ZZ7Va
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signatureto authorize inspection: Date:
OR
Owner/Agent's signature to decline p�(/ �7,Q Date: 3 .29 .2o.?
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building_Dlvlsion\Form5\RBR_6-15-22